Hot Seat #140: 5yoF with a Laceration
Posted on: November 7, 2019, by : Angelica DesPain
HPI: 5 yo F presenting with lacerations to left forehead and left eyelid from injury that occurred 29 hours ago. She was playing with her cousin on an electric toy car and jumped off, hitting her head on a metal bed rail. No LOC, no vomiting. Acting like herself, eating and drinking normally. No fevers or headaches.
Father did not bring patient in yesterday for repair because he was concerned that she would cry too much.
ROS
Constitutional: denies fever; normal energy; normal PO
Skin: laceration, no bruising, no swelling, no active bleeding
Resp: denies shortness of breath
GI: no vomiting
Neuro: no seizure, no altered level of consciousness
Heme: bleeding tendency negative
Past Medical History
No known drug allergies
No Medications
Immunizations are up to date
Physical Exam:
T 36.6 C, HR 116, RR 22, 99% RA
General: Alert, appropriate for age, cooperative, interacting
Skin: 1 cm laceration to muscle above left eyebrow with tissue splayed and healing; healing well-approximated 0.5 cm laceration over left eyelid
Head: Normocephalic
Neck: Supple
Eye: PERRL, EOMI, normal conjunctiva
ENMT: TMs clear, oral mucosa moist, dentition intact, facial bones intact
CV: RRR, no murmur
Resp: Lungs clear
GI: Soft, non-tender, non-distended
Musculoskeletal: Normal ROM, normal strength
Neurological: No focal neurological deficits
You decide to repair the laceration. You debride the tissue until you get to a part that bleeds. You have to put in one deep suture for muscle approximation and close with three simple interrupted sutures.
This is a tough topic because there is not good literature to guide the management. A Cochrane Review was attempted in October 2013 to answer this question entitled “Immediate closure or delayed closure for treating traumatic wounds in the first 24 hours following injury” and their conclusion was that “there is currently no systematic evidence to guide clinical decision-making regarding the timing for closure of traumatic wounds. There is a need for robust research to investigate the effect of primary closure compared with delayed closure for non bite traumatic wounds presenting within 24 hours of injury.” I did a review beyond 2013 and I was not able to find much. I also searched multiple textbooks including surgical textbooks and there is not a standard ‘golden period’ for laceration closure. That being said, all books highlight 24 hours as the upper limit. I think that beyond 24 hours I would not be comfortable with closure because epithelialization has started to occur and this requires that you actually debride the wound in order to perform the repair. Gary Fleisher said to me when I was a fellow that we are not surgeons and as EM physicians we should not be creating additional wounds, this should be left for a plastic surgeon. This is my practice, I know that others may practice differently but I generally do not cut further into wounds. I reached out to a friend who is a plastic surgeon, I will see what she has to say.
As for antibiotics, I would definitely treat beyond 12 hours with a first generation cephalosporin for staph and strep coverage.